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On November 30, 2012 the Department of Labor (DOL), filed an Amicus Brief in the Court of Appeals for the Third Circuit in support of plaintiff providers in an overpayment ERISA class-action. The DOL’s position on the pertinent issues includes:

Aetna must comply with federal law ERISA for all post-payment overpayment demands due to ERISA plan coverage dispute guidelines;

A healthcare provider with a valid assignment has federal rights to ERISA appeals and lawsuit in federal court;

Aetna’s hypothetical state law claims of fraud may not short-circuit federal ERISA procedural protections for both in-network and out of network providers and patients.

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According to the Court documents, the DOL advised the Court in part: “The crux of the question at issue here is not whether the plaintiff or the defendant is correct in their views of the plan terms, but whether Aetna must comply with the procedures mandated by ERISA section 503 and its accompanying regulations in rendering a determination based on a plan interpretation that is adverse to the plan participants and beneficiaries. Under the statute and regulations, the beneficiary or participant is entitled to a claims procedure that “afford[s] a reasonable opportunity . . . for a full and fair review by the appropriate named fiduciary of [a] decision denying [a] claim,” 29 U.S.C. §1133, and can then appeal the denial in federal or state court.” ….“Application of this term to “any” “reduction” or “termination,” and the reference to ” any utilization review” with respect to group health plans, makes plain that the claims regulations apply to post-payment, or retroactive, denials of health benefits.”

According to Court documents, the following is the Statement of Fact, in part, from the DOL Amicus Brief:

“Tri3 is a provider of medical equipment to, among others, participants and beneficiaries in ERISA health care plans insured by the defendant Aetna.”

“Aetna maintains a Special Investigations Unit (“SIU”) to detect and investigate incorrect or fraudulent insurance claims through post-payment audits.”

“Aetna rejected this evidence and concluded that, regardless of the billing code provided and its prior authorization of payment, no pneumatic compressors are covered under the plan and that the two devices at issue are, in any event, excluded from coverage because Aetna considers them to be experimental and/or investigational”, according to the court documents.

“Tri3, acting solely as an assignee of the beneficiaries and participants, sued Aetna pursuant to ERISA section 502(a)(1)(B) and for injunctive relief under section 502(a)(3)”, according to the court documents.

“Aetna moved to dismiss the claims, arguing that “the actions complained of arise in the context of fraud prevention and recovery” that other circuits have held may be pursued under state law without triggering ERISA preemption”, and “The district court granted the motion to dismiss”, according to the court documents.

DOL argued: “TRI3’S CLAIM THAT AETNA’S DEMAND FOR REIMBURSEMENT BASED ON A RETROACTIVE DENIAL OF BENEFITS ON GROUNDS THAT THEY WERE NOT COVERED BY THE PARTICIPANTS’ PLANS STATES AN ERISA CAUSE OF ACTION THAT THE DISTRICT COURT SHOULD NOT HAVE DISMISSED”, according to court the documents.

DOL Amicus Brief info: TRI3 Enterprises, LLC v. Aetna, Inc., Case No. 12-2308, Date Filed: 11/30/2012, in the United States Court Of Appeals for the Third Circuit, On Appeal from the United States District Court for the District of New Jersey.

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Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program. AVYM also offers free Webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support